ABSTRACT

Background

Writing narratives during medical training can provide a way to derive meaning from challenging experiences, enhance reflection, and combat burnout. The Yale Internal Medicine Residency Writers' Workshop, an annual 2-day intensive workshop followed by faculty-guided writing revision and publication, has been training resident physicians in the craft of writing since 2003.

Objective

The study aimed to assess the long-term effects of a craft-focused writers' workshop for residents on empathy, observation skills, and future writing.

Methods

A survey of closed and open-ended questions was sent to former workshop participants (2003–2013), who rated and described the workshop's influence on their observation skills, empathy, improvement in writing, and continued informal and formal writing. A total of 89 of 130 participants (68%) completed the online survey. We identified key themes in written responses and collected quantitative ratings on a 5-point Likert scale of self-reported influence on these factors. Simple statistics and narrative analysis were used to derive results.

Results

Most participants agreed or strongly agreed that the workshop influenced their ability for careful observation (72 of 85, 85%); ability to be empathic with patients or colleagues (51 of 77, 66%); quality of writing (69 of 77, 90%); and continued formal or informal writing (52 of 77 [68%] and 41 of 77 [53%], respectively). Participants felt the workshop improved their attention to detail, provided a deeper understanding of others' experiences, and improved their writing.

Conclusions

Participants in a residency writers' workshop experienced lasting effects on observation, empathy, and writing skills.

Introduction

In medicine, the process of narrative writing can provide a means of understanding one's own experiences, as well as those of others. Creative writing exercises in graduate medical education have traditionally focused on reflective writing as a way to process emotional reactions,17  counteract the loss of empathy, and address burnout and cynicism associated with medical training.8,9 

The focus of the Yale Internal Medicine Residency Writers' Workshop is not on reflection, but on the craft of writing. The workshop's initial cohort of participants reported that the focus on craft increased self-awareness and awareness of patients' humanity.10  After the workshop's 10th year, we sought to learn whether participating in this workshop had long-term effects on empathy, the ability to observe, and future writing.

Methods

The internal medicine department at Yale University trains 206 residents in traditional, primary care, and medicine-pediatrics residency programs.

A total of 130 residents participated in the initial 10 years of the writers' workshop from 2003 to 2013. The majority of participants (104) were from internal medicine, while 26 were from other specialties, including radiology, obstetrics and gynecology, anesthesiology, psychiatry, pediatrics, surgery, and emergency medicine.

The Residency Writers' Workshop is an annual 2-day workshop. Participation is limited to 12 to 14 participants in order to provide sufficient time to review each piece. The workshop is currently facilitated by 2 physician-writer faculty members (L.S. and A.R.). Estimated information regarding faculty time and workshop budget are provided in table 1. Workshop participants read all submissions before the workshop. On day 1, the group provides feedback on each written piece. Discussion includes style, efficient storytelling, and use of descriptive and precise language. The workshop includes creative writing exercises, such as “Places,” in which groups of 2 participants are instructed to leave the workshop room and find another location inside or outside. Each person writes a description of the location using language that engages all of the senses. Participants then return and share with the group. On day 2, participants share revisions from the previous evening and discuss ethical issues in writing and publication.

table 1

Estimated Annual Budget for Yale Internal Medicine Residency Writers' Workshop

Estimated Annual Budget for Yale Internal Medicine Residency Writers' Workshop
Estimated Annual Budget for Yale Internal Medicine Residency Writers' Workshop

In the 2 months following the workshop, participants revise their pieces with guidance from workshop faculty. Finished works are compiled in an annual publication, Capsules. Residents then give a reading for the medical community, and a visiting physician-writer presents medical grand rounds.

In April 2014, the 130 former workshop participants (2003–2013) were e-mailed a link to an online survey via Qualtrics (Provo, Utah). Prospective respondents were informed that responding to the survey denoted informed consent to participate. Periodic reminders were sent, and the survey closed in November 2014.

Survey questions included rating the workshop's influence on one's ability for careful observation, ability to be empathic, improvement in writing, and continued informal (diary, personal journal, etc) and formal (publication) writing, on a 5-point Likert scale (1, strongly agree, to 5, strongly disagree). Respondents were also asked to describe the most valuable component of the writers' workshop.

Simple statistics were derived from survey responses using the statistical reporting program supplied in Qualtrics. Narrative data per question were downloaded and placed in Microsoft Word (Redmond, Washington) for analysis. Four study personnel (M.L., J.E., L.S., and A.R.) reviewed free-text survey responses for 7 questions requiring written narrative answers. In pairs, reviewers performed open coding to identify themes for each of the 7 areas of response. Each dyad corresponded to reach consensus on codes. All 4 investigators discussed the preliminary codes and reached consensus on a final coding scheme. Final codes were then applied to all narrative questions by 1 investigator (M.L.), and then used by all 4 study personnel to achieve consensus on themes emerging from the textual responses.

This study was approved with exempt status by the Yale School of Medicine Human Investigation Committee.

Results

The final number of completed surveys was 89 of 130 (68% of the total population of participants). Not all participants completed all questions.

Effects on Observation

A total of 72 of 85 participants (85%) agreed or strongly agreed that workshop participation influenced their ability for careful observation. Participants described an increased attention to clinical detail after the workshop, including physical examination findings, clinical atmosphere, and patients' nonverbal cues (see table 2a for a representative quote).

table 2

Examples of Residency Writers' Workshop Participant Responses

Examples of Residency Writers' Workshop Participant Responses
Examples of Residency Writers' Workshop Participant Responses

Some participants commented that the workshop helped them frame patient details in a story format, which then helped them collect clinical information in an organized fashion. Others noted that they learned to include more nuanced descriptions and less jargon in their clinical documentation (table 2b).

Effects on Empathy

More than half of participants (51 of 77, 66%) felt that the workshop affected their empathy. Examining patient encounters through narrative writing and editing, as well as through listening to other participants share stories about experiences with patients, helped achieve a deeper understanding of the lived experiences of patients (table 2c and 2d).

Many participants described increased empathy toward their colleagues as a result of the workshop (table 2e.)

Effects on One's Own Writing

Nearly all of the participants (69 of 77, 90%) agreed or strongly agreed that the workshop improved their writing ability. Many noted that their writing improved through learning literary tools, such as “show, don't tell” and starting a story in the middle of an action (table 2f).

Participants expressed appreciation for the feedback and revision process during the workshop and for the focus on elements of good writing (table 2g).

Most participants (52 of 77, 68%) reported that they continued to write formally (for publication) or informally (diary, personal journal, etc; 41 of 77, 53%). They felt that they had become part of a community of writers, which increased confidence in their writing and editing. They also described an increased interest in reading nonacademic works. Some continued to use writing to process difficult clinical encounters (table 2h).

A total of 32 of 77 participants (42%) indicated that they had pursued additional writing opportunities to improve their skills, including writing classes, conferences, and collaborative writing projects.

Most Valuable Component

Some participants indicated that providing and receiving feedback in a group was the most valuable workshop component. They expressed gratitude at having found a community of physician-writers. Some described learning the value of writing as well as an increased motivation to seek publication. Some simply appreciated the value of having time allocated to write and reflect (table 2i).

Discussion

Participation in a writing workshop with a focus on craft may have long-lasting effects on resident physicians' observation skills, empathy, and continued writing.

There is renewed interest in training physicians to be more empathic. Medicare and Medicaid reimbursement is tied to patient satisfaction scores. Numerous formal programs have been created to bolster the empathy of resident physicians.1113 

Some argue that decreased time at the bedside and lack of focus on physical examination skills have resulted in poorer diagnostic skills.14,15  Several training programs have used visual arts to improve observation skills, but few have examined the role of the literary arts in teaching observation.1623  In a review, Wellbery and McAteer24  wrote that “literary precision provides an educational bridge to recognizing the importance of detail in the clinical realm.” Our participants felt that training in writing improved these skills beyond the time of the workshop.

Our study has several limitations. Participants are current and former medical residents who elected to take part in a writers' workshop, and their inherent interest in writing likely included a high baseline level of empathy and observation skills. We lack objective data about participants' level of empathy, observation skills, and writing skills prior to and after the workshop. Our data are limited to 1 institution, and results may not be generalizable. In future studies, participants' empathy and observation skills should be directly measured.

Conclusion

Despite the competing demands of residency training, participants in the first 10 years of the Yale Internal Medicine Residency Writers' Workshop completed meaningful narratives and reported effects on empathy, observation, and future writing.

References

1.
Wilkinson
J.
Writing workshops for third-year residents
.
Fam Med
.
2004
;
36
(
7
):
478
479
.
2.
Brady
DW,
Corbie-Smith
G,
Branch
WT.
“What's important to you?” The use of narratives to promote self-reflection and to understand the experiences of medical residents
.
Ann Intern Med
.
2002
;
137
(
3
):
220
223
.
3.
Charon
R.
Narrative and medicine
.
N Engl J Med
.
2004
;
350
(
9
):
862
864
.
4.
Scannell
K.
Writing for our lives: physician narratives and medical practice
.
Ann Intern Med
.
2002
;
137
(
9
):
779
781
.
5.
Charon
R.
The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust
.
JAMA
.
2001
;
286
(
15
):
1897
1902
.
6.
Branch
WT,
Suchman
A.
Meaningful experiences in medicine
.
Am J Med
.
1990
;
88
(
1
):
56
59
.
7.
Hatem
D,
Ferrara
E.
Becoming a doctor: fostering humane caregivers through creative writing
.
Patient Educ Couns
.
2001
;
45
(
1
):
13
22
.
8.
Neumann
M,
Edelhäuser
F,
Tauschel
D,
et al.
Empathy decline and its reasons: a systematic review of studies with medical students and residents
.
Acad Med
.
2011
;
86
(
8
):
996
1009
.
9.
Thomas
NK.
Resident burnout
.
JAMA
.
2004
;
292
(
23
):
2880
2889
.
10.
Reisman
AB,
Hansen
H,
Rastegar
A.
The craft of writing: a physician-writer's workshop for resident physicians
.
J Gen Intern Med
.
2006
;
21
(
10
):
1109
1111
.
11.
Riess
H,
Kelley
JM,
Bailey
RW,
et al.
Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum
.
J Gen Intern Med
.
2012
;
27
(
10
):
1280
1286
.
12.
Ziólkowska-Rudowicz
E,
Kladna
A.
Empathy-building of physicians. Part IV–development of skills enhancing capacity for empathy [in Polish]
.
Pol Merkur Lekarski
.
2010
;
29
(
174
):
400
404
.
13.
Kelm
Z,
Womer
J,
Walter
JK,
et al.
Interventions to cultivate physician empathy: a systematic review
.
BMC Med Educ
.
2014
;
14
:
219
.
14.
Verghese
A,
Horwitz
RI.
In praise of the physical examination
.
BMJ
.
2009
;
339
:
b5448
.
15.
Verghese
A,
Brady
E,
Kapur
CC,
et al.
The bedside evaluation: ritual and reason
.
Ann Intern Med
.
2011
;
155
(
8
):
550
553
.
16.
Schaff
PB,
Isken
S,
Tager
RM.
From contemporary art to core clinical skills: observation, interpretation, and meaning-making in a complex environment
.
Acad Med
.
2011
;
86
(
10
):
1272
1276
.
17.
Karkabi
K.
Visual thinking strategies: a new role for art in medical education
.
Fam Med
.
2006
;
38
(
3
):
158
.
18.
Shapiro
J,
Rucker
L,
Beck
J.
Training the clinical eye and mind: using the arts to develop medical students' observational and pattern recognition skills
.
Med Educ
.
2006
;
40
(
3
):
263
268
.
19.
Dolev
JC,
Friedlaender
LK,
Braverman
IM.
Use of fine art to enhance visual diagnostic skills
.
JAMA
.
2001
;
286
(
9
):
1020
1021
.
20.
Naghshineh
S,
Hafler
JP,
Miller
AR,
et al.
Formal art observation training improves medical students' visual diagnostic skills
.
J Gen Intern Med
.
2008
;
23
(
7
):
991
997
.
21.
Jasani
SK,
Saks
NS.
Utilizing visual art to enhance the clinical observation skills of medical students
.
Med Teach
.
2013
;
35
(
7
):
e1327
e1331
.
22.
Bardes
CL,
Gillers
D,
Herman
AE.
Learning to look: developing clinical observational skills at an art museum
.
Med Educ
.
2001
;
35
(
12
):
1157
1161
.
23.
Elder
NC,
Tobias
B,
Lucero-Criswell
A,
et al.
The art of observation: impact of a family medicine and art museum partnership on student education
.
Fam Med
.
2006
;
38
(
6
):
393
398
.
24.
Wellbery
C,
McAteer
RA.
The art of observation: a pedagogical framework
.
Acad Med
.
2015
;
90
(
12
):
1624
1630
.

Author notes

Funding: The authors declare no external funding source for this study.

Competing Interests

Conflict of interest: The authors declare they have no competing interests.

A limited form of these data was presented as a research poster at the Society of General Internal Medicine 38th Annual Meeting, Toronto, Ontario, Canada, April 22–25, 2015.